Category Archives: Procedures

REBOA Part 3a: How Do You Do It?

First off, this is 2-person procedure, minimum. It is possible with just one, but it’s a hell of a ride that way.

Also note that the technology continues to evolve. Earlier versions of his catheter required a 12 Fr sheath in the artery, but newer models have reduced this to 7 Fr. Older systems used a separate wire, whereas the newest model has a fused wire and catheter construct.

There are six separate steps in the process. So let’s discuss them, one by one.

Step 1. Access the artery

Sounds simple, but there are a number of considerations in this step. The end result is that a guidewire must end up in a large artery somewhere. The common femoral artery (CFA) is the vessel of choice, as anything more distal will rupture during the next step.

There are several ways to access the CFA. In some cases, a femoral arterial line may have already been inserted for other indications. Or maybe “just in case” REBOA might be needed. However, it’s important that the catheter is in the common femoral artery, not the superficial. This means that it must be inserted very close to the inguinal ligament.

If the patient still has vital signs, an arterial line may be inserted quickly, preferably with ultrasound guidance. However, if vitals have been lost, only a cutdown will assure rapid access to the artery.

Step 2. Insert and position the balloon.

First, make sure an x-ray unit is available, and position a plate underneath the patient’s body, from nipples downward. This is helpful for confirming positioning of the guidewire, if used. If not readily available, the wire and balloon can be marked based on external landmarks on the patient’s body.

For external marking, hold the REBOA next to the patient. For Zone I mark the catheter measuring from the groin to the xiphoid. Zone III should be marked with the balloon just above the umbilicus.

Now convert the existing wire to the appropriate size sheath for the REBOA catheter using the manufacturer’s instructions. Insert the REBOA unit, again following the directions for a wired or wireless catheter. Smoothly insert until your catheter mark is at the level of your sheath. Lock everything into place.

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Step 3: Inflate the balloon!

Whereas the previous steps only require some degree of technical skill, this one requires good judgment. The key is to get good occlusion without rupturing a vessel (the aorta!). This means inflating until you feel the pressure needed to add more volume start to increase disproportionately. Kind of like adjusting the cuff pressure on an endotracheal tube by feel.

I recommend inflating the balloon, not with plain saline, but saline with a bit of IV contrast mixed in. This allows you to verify balloon position using that x-ray unit and plate you so thoughtfully placed in the last step, or with fluoroscopy in the OR.

Tomorrow: Part 3b, more on how you do it.

Direct links to the REBOA series:

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REBOA Part 2: Who Will Benefit?

First, I would like to state that REBOA is not for the faint of heart. Hmm, not a very good idiom. It actually might be, if you are the patient.

I say this because REBOA has a definite learning curve from a technical standpoint. But it does use standard trauma and vascular surgical techniques, which makes it a little easier to grasp. At this point, it should primarily be performed by surgeons, since it frequently creates a vascular injury that requires surgical repair at the end of the procedure. However, to be fair, emergency physicians can and do initiate the procedure here and in some countries outside the US, such as Japan. Terminating it is another matter.

From a patient selection standpoint, think of it as a way of keeping your patient alive until you can get them to the OR for definitive control of their hemorrhage. You are trading 5 to 10 more minutes in the trauma bay inserting it for a (potentially) safer trip to the OR suite, and lets the surgeons start the case with some modicum of vascular control already in place.

The abdomen is divided into 3 REBOA zones, depending on where the hemorrhage is located. Here’s the map:

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For bleeding in the abdominal cavity, the REBOA balloon is placed in Zone I. For practical purposes, we try to occlude the distal aorta at the diaphragm, where we would normally place the crossclamp for an ED thoracotomy.

For pelvic bleeding, generally from branches of the iliac arteries, the balloon is placed in the distal aorta, Zone III. Zone II is not used currently.

So who will benefit from REBOA? The answers to this question are still being teased out of the small series that are being produced by a number of centers. The general rule is that any patient with exsanguinating hemorrhage originating below the diaphragm should be considered for this procedure.

Does that mean all patients? Patients who still have vital signs? How good or bad do they need to be? Unfortunately, we don’t know yet. But we are working on it.

Monday: How is REBOA performed?

Direct links to the REBOA series:

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REBOA Part 1: What Is It?

Technically, REBOA is the acronym for Resuscitative Endovascular Balloon Occlusion of the Aorta. It is a relatively new tool in our armamentarium for use in patients with uncontrolled hemorrhage. Essentially, it allows the surgeon to crossclamp the aorta at just about any level, without opening the chest or abdomen.

But as with anything new, it is usually derived from something old. And REBOA is no exception. Case reports surfaced in the Korean war, and continued through the 1980s. The technique was then adopted by vascular surgeons and used for controlling hemorrhage above a ruptured abdominal aortic aneurysm. As with most major trauma “discoveries”, military conflict also tends to foster the development of new and the refinement of existing techniques.

The early part of this decade was actually the heyday for animal testing of this technique. Numerous pigs were sacrificed in order to show that 1) it could be done relatively safely, 2) it definitely increased blood flow to the brain and heart, and 3) it decreased mortality. Finally, the technique was shown to have similar effects and outcomes to pig thoracotomy with cross-clamping.

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The first small human series was published just a year ago, so our experience is relatively short and limited to small series. But it continues to grow steadily, and more and more trauma centers are beginning to dabble with the technique.

Tomorrow: Who would benefit from REBOA?

Direct links to the REBOA series:

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Air Embolism From an Intraosseous (IO) Line

IO lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

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How Do You Dress YOUR Trauma Team?

Over the years, I’ve seen the trauma teams at quite a few hospitals in action. One thing I have noticed is that most just don’t pay attention to what they wear. I’m talking about wearing personal protective equipment again. It’s one of those things, like hand washing, that everyone knows that they are supposed to do.

There are two reasons to put all that stuff on:

  • To keep potentially contaminated body fluids from getting on you
  • To prevent you from contaminating your patient’s open wounds

The minimum equipment that MUST be worn is a cap of some sort (to keep your hair from falling on the patient), mask and eye protection (mucus membrane protection), gown (protects your clothes), and gloves (obvious). Shoe protection is optional, in my opinion, unless you wear Christian Louboutin to work.

So you’ve been lax with your team. How do you get them to put everything on now? It’s like getting your child to wear a bicycle helmet when they are fourteen.

  • Create an expectation that everyone wear it and empower everyone to point it out. No exceptions. Physicians, this means you.
  • Put all equipment just outside the trauma room door. The farther away it is, the less likely it is to be used.
  • Assign an enforcer. Everyone entering the room must be dressed, or this person will speak up. Ideally, they should be a physician. If not, one of the docs must back this person up.
  • Occasionally, a badly hurt patient gets rolled into the room with little advance notice. In this case the fully dressed people need to relieve those who are not as soon as they dress and walk into the room.

The top picture shows part of our trauma team assembling before a trauma activation. Everyone is dressed. They know that someone will call them on it if they aren’t. Also, note the little pink sticker on the chest of physician at the head of the bed. We have a sticker for every role in the room (bottom picture). At the beginning of a resuscitation I scan the room to make sure everyone has one. It helps identify everyone and makes extraneous personnel stand out so they can be asked to leave the room.

Bottom line: Everyone has to wear their personal protective equipment on every trauma resuscitation. No exceptions.

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